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General Surgery > Head, Neck And Breast Surgery > Flashcards

Head, Neck And Breast Surgery Flashcards

1
Q

List the non-hereditary risk factors for breast cancer

A

Older patient >50 years

Females

Alcohol and smoking

Early menarche

Late menopause

Late first pregnancy/few or no pregnancy

Obesity

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2
Q

List the hereditary risk factors for breast cancer

A

BRCA 1 or BRCA 2 mutation
* BRCA 1 mutation - 85% chance of developing breast ca

Family history of breast cancer

Family history of ovarian cancer

Personal history of breast cancer

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3
Q

What patients are considered high risk for breast cancer?

A

> 1 first line relative with unilateral breast ca

1 first line relative with bilateral breast ca

1 male relative with breast ca

1 relative with breast or ovarian ca

Previous biopsy showing

  • CIS
  • Proliferative disease with atypia
  • complex fibroadenoma
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4
Q

How is breast cancer diagnosed?

A

Triple Test!!

  1. Clinically
    * History - Risk factors
    * Exam - Lump/mass and LN
    * Metastases
  2. Mammogram
    * 2 views - CC and MLO
    * Suspicious lesion
  3. FNA and Cytology
    * ER/PR status
    * Pathological type
    * Inconclusive > Core biopsy
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5
Q

What is the importance of ER/PR status of a breast carcinoma

A

ER/PR (+) must NOT get hormone Replacement therapy because it feeds the tumour

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6
Q

What are the features of a suspicious lesion on mammogram?

A

Hyperdense

Spiculated

Pleomorphic microcalcifications

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7
Q

What are the most common pathological types of breast cancer?

A

Infiltrating ductal (75%)

Infiltrating lobular (10%)

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8
Q

What are the management guidelines for a Stage I-II breast cancer?

A

Breast conservtaion therapy with adjuvant radiotherapy

Systemic therapy depending on prognostic factors of the tumor

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9
Q

What are the indications for Neo-adjuvant chemotherapy in breast cancer?

A

All locally advanced disease - Stage IIb; IIIa and IIIb

> 4cm mass

To downstage a tumor

If increased risk of micrometastases

To decrease tumour size

HER (+)/(-)

Triple negative - ER/PR/HER (-)

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10
Q

What are the indications for Adjuvant chemotherapy in breast cancer?

A

Age <40 years

ER / PR (-)

> 3 LN involvement

High grade tumours

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11
Q

What are the indications for hormone therapy in breast cancer?

A

ER (+)

Soft tissue metastases

Bone metastases

Pleural effusion (lung metastases)

Local reccurrance

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12
Q

What are the indications for a mastectomy (contraindications for BCT) in breast cancer?

A

High breast : tumour ratio

Previous irradiation to the breast

Multifocal/multicentric tumour

Wide spread microcalcifications on mammography

Tumor > 4cm

BRCA (+)

Patient preference

Collagen vascular disease - coz’ radiotherapy C/I

  • SLE
  • Scleroderma

2 Recurrence of carcinoma

Males

Poor socio-economic circumstances

Pregnancy / Lactation

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13
Q

What hormone therapy would you use in a post-menapausal woman with breast cancer?

A

Tomoxifen

  • Inhibits oestrodiol binding
  • Especially effective in ER/PR (+) patients

Anastrozole (Arimidex)
* Aromatase inhibitor - inhibits the conversion of androgens to oestrogen

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14
Q

What are the side-effects of tomoxifen?

A

Menopausal symptoms:

  • Hot flushes
  • Mood changes
  • Altered menses / amenorrhoea
  • Dry vagina
  • Thrush

Thromboembolism

  • Stroke
  • DVT

Fatty liver changes

Increased risk of endometrial cancer

Vaginal atrophy and bleeding

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15
Q

What are the side-effects of Arimidex?

A

MSK pain

Bone pain

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16
Q

What hormone therapy would you use in a pre-menapausal woman with breast cancer?

A

Ovarian ablation

  • Surgical
  • GnRH antagonist - Temporary, better for younger patients

Tomoxifen

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17
Q

What receives biological therapy in breast cancer and biologic would they receive?

A

HER-2 (+) patient

Herceptin - monoclonal antibody against HER-2

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18
Q

Discuss regional therapy in breast cancer

A

Palpable Axillary LN
* Axillary dissection via Modified radical mastectomy

Impalpable Axillary LN
* Sentinal LN biopsy

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19
Q

Discuss BRCA

A

Autosomal dominant inheritance

Associated with breast, ovarian, fallopian tube, colon and prostate carcinoma

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20
Q

What stage breast cancers would you do a CT scan and bone scan for?

A

Stage IIb and up

To look for Metastases

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21
Q

What are the histological indications for axillary dissection in breast cancer?

A

Large tumour

Soft tissue invasion

3 or more LN had tumour in it

Extranodal extension of disease

Micrometastases

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22
Q

What special investigations would you do in a patient with thyroid pathology and why?

A

Serum TSH

  • Raised in hypothyroidism
  • Decreased in hyperthyroidism and euthyroidism

Total T4, free T4 and free T3
* Function of the thyroid

Serum Calcitonin
* Increased in MEN 2 syndrome

Thyroid Antibodies
* Increased in autoimmune thyroiditis

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23
Q

Discuss the use of thyroid function tests (TFT)

A

Elevated TSH and low FT4 = Primary hypothyroidism due to disease in the thyroid gland

Low TSH and low FT4 = Hypothyroidism due to a problem involving the pituitary gland

Low TSH with an elevated FT4 and FT3 = Hyperthyroidism.

24
Q

Discuss Radioactive Iodine (RAI) Uptake testing

A

Provides a function-anatomical correlation of thyroid lesion

Provides information on risk of malignancy

Cold nodule = High risk of malignancy (20%)

Hot nodule = Lower risk of malignancy (5%)
* Hot nodule + hyperthyroidism = benign

25
Q

What imaging would you do in a patient with thyroid pathology and why?

A

RAI uptake
* Provides information of risk of malignancy

FNA
* Diagnoses/excludes malignancy

Ultrasound
* Evaluation of thyroid nodules for suspicious signs of malignancy

CT scan
* Metastases

26
Q

What are the suspicous signs of thyroid cancer on ultrasound?

A

Calcification

Increased vascularity

Irregular borders

Absent halo sign

27
Q

What is the most common thyroid malignancy?

A

Papillary cell adenocarcinoma

28
Q

What is the origin of a Papillary cell adenocarcinoma of the thyroid?

A

Arises from follicular epithelial cells

29
Q

What are the risk factors for a Papillary cell adenocarcinoma of the thyroid?

A

Genetic mutation of BRAF gene

Previous irradiation

Family history of thyroid cancer

Familial syndromes:

  • Familial papillary carcinoma
  • Familial non-medullary thyroid carcinoma
  • Familial adenomatous polyposis coli (FAP)
  • Gardner syndrome (Familial colorectal polyposis)
  • Turcot syndorme (multiple adenomatous polyps in the colon)
30
Q

What is the clinical presentation of a Papillary cell adenocarcinoma of the thyroid?

A

Most common (80%)
2:1 female:male ratio
20-30 years

Solitary nodule

  • Firm on palpation
  • Solid on ultrasound
  • Cold on RAI

Dysphagia (invasive)

Dyspnoea (invasive)

Dysphonia (invasive)

Palpable LN

31
Q

What is the route of spread of a Papillary cell adenocarcinoma of the thyroid?

A

Lymphatic

32
Q

Where does a a Papillary cell adenocarcinoma of the thyroid metastasize to?

A

Lungs

Bone

33
Q

What investigations would you do for a papillary cell adenocarcinoma of the thyroid??

A

Thyroid function tests

  • Increased TSH
  • Normal FT3 and FT4

Ultrasound

  • Look for suspicious signs
  • Solid

FNA and cytology

  • Papillary projections of columnar epithelium
  • Psammoma bodies (60%)

RAI
* Cold

34
Q

What is the management of a Papillary cell adenocarcinoma of the thyroid?

A

Surgical
<1 cm - Lobectomy/Isthmustectomy (Younger patients)
>1 cm - Total thyroidectomy with central node dissection

Adjuvant

  • Thyroid hormone suppression and radioiodine therapy
  • External beam radiotherapy for >45 years and had locally invasive disease.

Post-Total thyroidectomy
Life-long thyroid hormone replacement therapy

35
Q

What are the indications for a Total thyroidectomy?

A

(Also contraindications to RAI)

Large/Multinodular goitre with poor RAI uptake

Compression symptoms

Suspicious malignant nodule/ confirmed thyroid cancer

Pregnancy/children

Patients who wish to fall pregnant

Amioderone induced hyperthyroidism

Adverse effects of antithryoids

Unable to follow long term follow-up

36
Q

What are the complications of thyroidectomy?

A

Thyroid storm

Neck haematoma

Recurrent laryngeal nerve injury

Injury to the external branch of the superior laryngeal nerve

Injury to the oesophagus

Injury to to the great vessels/cervical sympathetic trunk

Hypoparathyroidism

37
Q

Provide a DDx for a solitary nodule of the thyroid

A

Cyst

Colloid nodule

Papillary cell adenocarcinoma

Follicular cell adenocarcinoma

38
Q

What is the origin of a medullary carcinoma of the thyroid?

A

Arises from the parafollicular cells

*Secretes calcitonin and CEA

39
Q

What are the risk factors for medullary carcinoma of the thyroid?

A

RET oncogene on chromosome 10

MEN syndrome 2A and 2B

40
Q

What is the presentation of medullary carcinoma of the thyroid?

A

Sporadic type
* Unilateral, solid, hard, nodular neck mass

Familial type
* Bilateral/multicentric hard, nodular neck mass

41
Q

What is the route of spread for medullary carcinoma of the thyroid?

A

Haematogenous

  • LN
  • Bone
  • Lung
42
Q

Where does a medullary carcinoma of the thyroid metastasize to?

A

Early

  • Adjacent muscle
  • Trachea
  • Local and mediastinal LN

Late

  • Bones
  • Lungs
  • Liver
  • Adrenals
43
Q

How would you diagnose a medullary carcinoma of the thyroid?

A

Bloods

  • Raised Calcitonin
  • Raised CEA

FNA

RAI
* Cold

44
Q

How would you manage a medullary carcinoma of the thyroid?

A

(If present, phaeochromocytoma should be managed first)

Total thyroidectomy + modified neck dissection if cervical LN affect

45
Q

Define MEN syndrome

A

It is a group of autosomal dominant disorders characterized by the growth of benign and malignant endocrine tumours

46
Q

What are the clinical features of MEN-1 syndrome?

A

Hyperparathyroidism

Pancreatic tumours

Pituitary adenomas

Adrenal adenoms

Carcinoid tumours

47
Q

What is the management of MEN-1 syndrome?

A

Hyperparathyroidism

  • Medical - Calcimimetics
  • Surgical - Parathyroidectomy with thymectomy

Gastrinomas
* Medical - PPI’s (omeprazole)

48
Q

What are the clinical features of MEN-2A syndrome?

A

Medullary carcinoma of the thyroid (80-100%)

Phaeochromocytoma (40%)

  • HPT
  • Headaches
  • Palpitations
  • Diaphoresis
49
Q

How would you diagnose MEN-2A syndrome?

A

Genetic testing - RET mutation

Serum calcitonin after 3 days of omeprazole

50
Q

What is the management of MEN-2A/2B syndrome?

A

Medullary carcinoma of the thyroid
* Prophylactic thyroidectomy in kids with RET mutation

Phaeochromocytoma

  • alpha-blockers + beta-blockers
  • Unilateral/bilateral adrenalectomy
51
Q

What are the clinical features of MEN-2B syndrome?

A

Medullary carcinoma of the thyroid

Mucosal neuromas
* Bumpy, enlarged lips and tongue

Phaeochromocytoma

  • HPT
  • Headaches
  • Palpitations
  • Diaphoresis

Skeletal abnormalities

Marfanoid habitus

52
Q

What is the most common salivary gland neoplasm?

A

Parotid tumours - Benign pleomorphic adenoma

53
Q

What is the clinical presentation of a malignant parotid mass?

A

Rapid growth

Pain

Paraesthesia

Facial nerve (CN VII) weakness/palsy

Skin invasion and fixation to mastoid tip

54
Q

How would you diagnose a salivary gland tumour?

A

FNA

Surgical excision
* Provides a definite histopathological diagnosis

MRI

  • Better soft-tissue visualization
  • Can see soft tissue extension and involvement of adjacent structures
55
Q

How would you manage a benign pleomorphic adenoma of the parotid gland?

A

Superficial parotidectomy with preservation of the facial nerve

56
Q

What are the indications for adjuvant radiation therapy in salivary gland tumours?

A

Extraglandular disease

Perineural invasion

Direct invasion of regional structures

Regional metastases

High-grade histology

General Surgery (7 decks)

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